1. 2nd trimester Miscarraige
Dr. Alia kareem

2. Lecture headlines
Definition
Incidence
Causes
Incompetent cervix

3. Definition
Miscarriage is a spontaneous pregnancy loss before the gestational age of fetal viability

4. Gestational age of fetal viability
Viability implies the ability of fetus to survive extra uterine life
this is generally considered to occur at 24 weeks gestation.

5. second trimester miscarriage
Is a spontaneous pregnancy loss occurs between 12and 24 weeks gestation

6. Incidence
2nd trimester miscarriage constitutes <3% of all pregnancy outcomes.

7. Etiology
aetiology underlying late miscarriage varies with gestational age.
Conditions associated with2nd trimester pregnancy loss overlap those of the 1st and third trismeters.
The predominant causes of losses at 12– 16 weeks are those of first trimester miscarriage

8. Etiological factors
Idiopathic
Fetal
maternal

9. Fetal factor
The predominant causes of losses at 12– 16 weeks are fetal chromosomal and 'structural anomalies

10. Maternal factor Anatomical factors: A- uterine anomaly :
-congenital(septate &bicornuate uterus).
-acquired: Asherman syndrome
B-cervical incompetent

11. Infection
Endocrine disease
Acute sever illness
Thrombophilia
Over distension of uterus
Abdominal, pelvic surgery
amniocentesis

12. Cervical incompetent
Is an inability of cervix to retain pregnancy in abscence of uterine contraction or labour.

13. Etiology of cervical incompetent
Congenital :Congenital exposure to DES in utero , connective tissue disorders
Acquired:(dilatation and curettage, conization, cauterization, or amputation,cx laceration following SVD

14. Clinical presentation
Cx dilatationand effacement in the 2nd trimester with fetal membrane visible at or beyond the ext.osin absence of contraction

15. Dignosis before pregnancy: -Historical features:
Hx of tow or more 2nd trimester pregnancy loss
Hx of pregnancy loss at an earlier gestational age
HX of painless cx dilatation up to4-6 cm
Absence of clinical finding consistent with placenta abruptio
Hx of cx trauma

16. investigation Before pregnancy
Easily passing of 8 Hegar dilator through cx with no resistence
Funneling of IO on HSG
During pregnancy:TVU of cx:
Short cx: <25mm before 24 weeks
Funneling of membrane through IO

17. Normal CX(a) shortcx(b)

18. Treatment approach
Cervical cerclage surgically reinforces a weak cervix by some type of purse-string suturing

19. Types according to indication
Prophylactic cx cerclage
cerclage should be offered to women with three or more previous preterm births and/or second-trimester losses
Women with a history of one or more spontaneous mid-trimester losses or preterm births who are undergoing transvaginal sonographic surveillance of cervical length should be offered an cerclage if the cervix is 25 mm or less and before 24 weeks of gestation.

20. 2-Rescue cx cerclage Insertion of cerclage as a salvage measure in the case of premature cervical dilatation with exposed fetal membranes in the vagina in absence of ut.contraction.

21. Types according to surgical approach
1-Transvaginal cerclage (McDonald)
2- High transvaginal cerclage (Shirodkar)
3- Transabdominal cerclage

22. 1-Transvaginal cerclage (McDonald) A transvaginal purse-string suture placed at the cervicovaginal junction, without bladder mobilisation.

23. High transvaginal cerclage (Shirodkar) A transvaginal purse-string suture placed following bladder mobilisation, to allow insertion above the level of the cardinal ligaments.

24. 3- Transabdominal cerclage A suture performed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction.

25. Time of application
Transabdominal cerclage can be performed preconceptually or in early pregnancy.
Trans vaginal cerclage at weeks

26. Time of removing A transvaginal cervical cerclage should be removed :
between 36+1 and 37+0 weeks
Labour
PROM
IUD

27. All women with a transabdominal cerclage require delivery by caesarean section, and the abdominalsuture may be left in place following delivery.

28. Contraindications for cx cerclage
active preterm labour
● clinical evidence of chorioamnionitis
● continuing vaginal bleeding
● PPROM
● evidence of fetal compromise
● lethal fetal defect
● fetal death.

29. Complications of cx cerclage
-1-during insertion of cervical cerclage.
small risk of:
intraoperative bladder damage,
cervical trauma,
membrane rupture and bleeding
2- Shirodkar cerclage usually requires anaesthesia for removal and therefore carries the risk of anadditional anaesthetic.
3- Cervical cerclage may be associated with a risk of cervical laceration/trauma if there is spontaneouslabour with the suture in place.